Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D-3189 | ID |
NPI | 1003189366 |
---|---|
Provider Name | John Joseph Johnson |
First Address | Lewiston, ID 83501 |
Second Address | Lewiston, ID 83501 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/02/2012 |
Last Update Date | 17/02/2012 |